BNH N

A. HNH CHNH.
I. H v tn: NGUYN GIA BO
nam
10 thng.
II. Dn tc: Kinh
III. H v tn b: Nguyn Qun Vng Trnh vh: 12/12 ngh nghip: cng nhn.
IV. H v tn m : L Th Huyn
Trnh vh: 12/12 ngh nghip: nng dn.
V. a ch: n Vin Cao Vin Thanh Oai H Ni.
VI. Ngy vo vin: 31/08/2014
VII. Lin lc: m cng a ch - 01653457237.

B. CHUYN MN
I. L do vo vin:
St cao, ho
II. Bnh s:
Bnh din bin hn 1 thng nay, ban u tr xut hin st cao, nhit dao ng
khong 38-39,5C, km theo tr ho nhiu, ho c m, tr khng nn, khng co
git, gia nh cho dng h st th h c st, sau st li. Tr c nhp bnh
vin huyn, iu tr 15 ngy vi chn on VPQP, tr vn st, vn ho nhiu, c
chuyn ln BV Nhi T, iu tr ngoi tr 10 ngy, vi chn on VPQP khng
st, ho nhiu, tr c nhp vin Nhi T iu tr 10 ngy ti A16 vi chn on
VPQP, tr ht st, vn cn ho. Tr ra vin v iu tr ti nh theo n, tr vn ho,
n ngy th 4 tr xut hin st cao 39,3C, tr nhp vin Nhi T.
III. Tin s
1. Tin s bn thn:
a) Tin s sn khoa:
Tr l con th 2, thng, thng, ra khc ngay, khng cn hi sc, cn nng lc
: 3,2kg.
b) Tin s dinh dng:

- B m ngay sau khi sinh, m sa, hin vn cn b.

- n b sung t thng th 5, n thm sa ngoi, bt, cho.
- Hin ti: tr n km hn mi khi, b t.
c) Tin s pht trin:
- Tr ngi vng t thng th 6.
- Tr ng vn vng, i men theo vt chn c.
d) Tin s bnh tt:
- Khe mnh
- Khng c d tt bm sinh.
e) Tin s tim chng:
Tr tim y : lao, hg-bh-uv, bi lit, si, VGB.
2. Tin s gia nh
Cha pht hin g c bit.
IV. Khm
1. Khm ton thn:
- Tr tnh, chi ngoan
- Th trng trung bnh: cn nng 8,9kg
- Da nim mc nht nh
- Khng ph, khng xut huyt di da.
- Lng tc mng bnh thng.

- SpO2: 97%; nhit : 38,5C

2. Khm h hp:
- Lng ngc cn i
- Tr th u, nhanh 58l/p, th bng
- Phi RRPN gim 2 bn
- Rale m nh ht 2 bn, rale ngy, rale rt.
3. Khm tim mch
- Mm tim KLS 4, ngoi ng v tri.
- Tim u, tn s 160l/p
- T1,T2 r, khng ting thi bnh l.
4. Khm tiu ha:
- Bng mm khng chng
- Gan lch khng to.
- i ngoi phn lng 3 ln/ngy, phn t.
- Nn, tr khi ho.
5. Khm thn kinh:
- HCMN (-)
- Khng c DhTKKT
6. Khm c xng khp:
Cha pht hin g bt thng.
7. Khm tai mi hng:

Hng , sng.
8. Khm cc c quan khc
Cha pht hin g bt thng.
V. Tm tt bnh n.
Bnh nhn nam, 10 thng tui, vo vin v st cao, ho nhiu, bnh din bin hn 1 thng
nay, qua thm khm v hi bnh pht hin cc triu chng v hi chng sau:
- Hi chng nhim trng.
- HC vim long ng h hp trn.
- Phi: nhiu rale m nh ht, rale ngy, rale rt.
- Nhp th nhanh, khng c RLLN.
- Hng .
VI. Chn on s b
Vim ph qun phi, khng c suy h hp.
VII. Chn on phn bit:
1. Vim tiu ph qun phi.
2. Hen ph qun.
3. Ho g
VIII. Cn lm sng
1. Cc xt nghim yu cu
- XQ tim phi
- Cng thc mu

- Sinh ha mu: CRP

2. Kt qu
- XQ: m m nh khng u, ri rc 2 rn phi
- CTM:
BC: 15,93 G/l
NTT: 60,1%
Lym: 28,4%
HC: 4,97T/l
Hb: 99g/l
MCV: 64,1fl
Hct: 30,5%
MCHC: 325g/dl
TC: 370
- Sinh ha:
CRP: 8,03 mg/l
IX. Chn on xc nh
Vim ph qun phi, thiu mu hng cu nh.
X. iu tr
1. Nguyn tc
- Chng nhim khun
- Chng suy h hp
- iu tr cc ri lon nc, in gii, thng bng kim toan
- iu tr cc bin chng nu c.
2. C th
- Chng nhim khun:
Tarceforsym: 500mg/ngy
- Chng suy h hp:
Cho tr nm ni thong mt, yn tnh, ni rng qun o.
Thng thong ng th: ht m ri, kh dung
Ventolin 2,5mg x 1 ng
Pulmicort 500g x 1 ng
- Bi ph nc v in gii
- Chm sc:
theo di thng xuyn : nhp th, mch
cho tr n, b m y
Xoay tr tr thng xuyn.